Reversal of antithrombotic medications in patients with traumatic brain injury: What you need to know

Traumatic brain injury (TBI) is a major public health problem and patients with TBI are frequently encountered by trauma surgeons. When TBI occurs in patients who are also taking antithrombotic medications, the risks and complications are increased. Antithrombotic medications can be classified as antiplatelet agents or anticoagulants. Examples of antiplatelet agents include aspirin and clopidogrel. Anticoagulant medications include vitamin K antagonists like warfarin, direct oral anticoagulants, and unfractionated or low-molecular-weight forms of heparin. Each of these agents alter the hemostatic balance through different mechanisms and therefore require distinct reversal strategies. Initial management of TBI in patients receiving antithrombotic agents includes prompt neurological assessment, non-contrast head computed tomography, and laboratory testing to assess coagulation status. Decisions regarding possible reversal of antithrombotic medications must be guided by the severity of injury, bleeding risk, patient co-morbidities, and the specific agents used. This review will discuss what trauma surgeons need to know in terms of managing patients with acute TBI who are taking anticoagulant and antiplatelet medications based on the current literature.